Making Singapore a Healthy Urban City

“World’s healthiest nation(1) ”, “one of the most efficient public healthcare systems(2) ”, “Singapore ranks world number
4 for life expectancy(3) ”; these are just a few of the accolades paid to Singapore in recent years. How did a small nation-state transform itself from a
country with poor health outcomes to one of the best in the world in a span of just 50 years?

INTRODUCTION

This was largely due in part to a government that understood very early on the need to integrate health with every aspect of urban planning. Housing, water, food, air quality, road traffic,
parks, is all seen as key components in a holistic health system(4) .

In the early years of Singapore’s independence, health issues mainly pertained to poor nutrition and hygiene factors. Health education focused on teaching a largely uneducated population to
practise preventive measures like hand-washing and boiling drinking water. As Singapore developed, the government started putting in place accessible and affordable quality health services. The
investment in the health system was complemented by further government investments in an effective public health system such as the provision of clean drinking water and good sanitation, the
enforcement of food safety standards and pollution control. Singapore also set up an entire government agency, the Health Promotion Board (HPB), which is dedicated to promoting healthy diets,
exercise, health education and regular screenings among Singaporeans.

School-going children undergoing health checks carried out by the Health Promotion Board’s School Health Service(5).

With the government’s commitment to create a holistic health system, Singaporeans are now able to reap the benefits of medical technological advances and accessible quality medical care. This was
a far cry from the 1950s and 60s when there was a lack of access to basic medical care and children were undernourished. At the same time, the country has also experienced improvements in its
health outcomes, with health promotion efforts playing an integral role in shaping the health of the Singapore population. Today, Singapore’s obesity and smoking rates are the lowest among the
OECD countries(6) .

THE GROWING PROBLEM OF NON-COMMUNICABLE DISEASES

“Instead of diseases vanishing as living conditions improve, socio-economic progress is actually creating the conditions that favour the rise of non-communicable diseases. Economic growth,
modernisation, and urbanisation have opened wide the entry point for the spread of unhealthy lifestyles.”

Dr Margaret Chan, Director-General of World Health
Organisation(7)

As the Singapore’s economy improved, so too did the lifestyles of its population. Growing affluence with increasingly sedentary lifestyles meant that health issues started to shift from those of
malnutrition and infectious diseases to non-communicable diseases.

By 2010, about 70% of the burden of premature deaths and ill health in Singapore was caused by non-communicable diseases such as diabetes, heart disease, and cancer(8) . Nearly a quarter of this burden of disease had been attributed to modifiable lifestyle risk factors, with the top two being high body mass and cigarette
smoking(9) .

Singapore’s population is also rapidly ageing. The number of people aged 65 and above has been projected to more than double from 405,000 to 900,000 by 2030(10) . This means that it is highly likely that more people will suffer from non-communicable diseases in the next decade.

This has also been compounded by a sharp increase in obesity rate from 6.9% to 10.8% between 2004 and 2010(11) . The Saw Swee Hock School of Public Health
(SSH SPH) has projected that one in nearly six people in Singapore will be obese by 2050(12) . Besides obesity, smoking is also a problem. Despite strong
legislative measures, smoking rates among adults crept up to 14.3% in 2010 from 12.6% in 2004(13) .

In the light of these challenges, Singapore has recognised the need for a sustainable model to ensure good health for the population. Besides investing more in acute care, there has to be
an even stronger focus on preventive health – keeping the population healthy even as they live longer. This provided the impetus for the Health Promotion Board to shift from building awareness of
health issues to influencing Singaporeans’ lifestyle behaviours. As such, the Health Promotion Board’s strategies have to go beyond public education to helping Singaporeans adopt and sustain
healthy habits. Simple changes in lifestyles – exercising regularly, eating healthily, not smoking and going for regular screenings and prompt treatment of chronic diseases – can go a long way in
preventing many non-communicable diseases

An example of a visual cue to 'nudge' Singaporeans to use the stairs.

THE HEALTHY LIVING MASTER PLAN – HEALTHY LIVING EVERY DAY

“Each of us is responsible for our own health. The first thing we need to tackle is our own behaviour....We aim to catalyse a whole-of-Singapore effort, in which healthy living becomes a
shared vision.”

Gan Kim Yong, Minister for Health, Singapore(14)

With a constantly evolving health landscape, there is a continuing need to review current efforts to harness new opportunities and deal with emerging challenges to help Singaporeans adopt and
sustain healthy habits. Surveys(15) conducted showed that even though many Singaporeans appreciated the importance and benefits of healthy living and
healthy lifestyle habits, it could be challenging for individuals to put these into practice due to the many competing needs and wants in their daily lives.

In response to this and to facilitate the integration of nation-wide efforts in enabling healthy living, the Healthy Living Master Plan Taskforce was formed in September 2012. The aim of the
Taskforce was to review the existing health promotion and disease prevention landscape in Singapore and to formulate a systematic plan, consolidating the inputs of various public agencies and
community organisations, along with views from the public. These efforts culminated in the Healthy Living Master Plan.

Launched in 2014, the Master Plan aims to make healthy living accessible, natural, and effortless for all Singaporeans. Through this Master Plan, it is envisioned that Singapore in 2020 will have
healthy living at the “doorstep” of every home, workplace and school, so that Singaporeans can embrace healthy living as part of their everyday routine. To realise the vision of “Healthy Living
Every Day”, a two-pronged approach is key – a whole-of-government effort and co-creation with the community.

Above and beyond these two prongs, to create an environment supportive of healthier choices, the government also partners the private sector to “tilt the market” so that supply would be generated
and demand created for more healthier options in the market.

“Singaporeans agree more can be done to improve their health, particularly in the areas of physical activity and regular health screening. However, such awareness has not yet prompted
Singaporeans to proactively adopt a healthier lifestyle”.

AIA 2013

Healthy Living Index Survey

HLMP anchor initiatives at a glance.

WHOLE-OF-GOVERNMENT APPROACH IN THE HEALTHY LIVING MASTER PLAN

“Health would be affected by almost every aspect of life in an urban setting: housing, water supply, food supply, air quality, waste disposal, road traffic, parks, tree planting, and more.
Ensuring the health of the people of Singapore had to be built into every aspect of urban planning, requiring a comprehensive approach and the cooperation of numerous ministries over all the
various sectors of government.”

Dr William A. Haseltine, Chairman and president of ACCESS Health International Inc(16)

Governments today have had to adopt whole-of-government thinking as a matter of necessity, as issues become increasingly more complex and multi-faceted. This approach helps governments to tap on
diverse knowledge, viewpoints and ideas from across the public sector, creating synergy as different agencies come together to broaden and deepen policy development. Concerted and coordinated
whole-of-government efforts often achieve greater outcomes than the most competent agencies working alone(17) .

Health is no exception to complexity. Health authorities worldwide have increasingly recognised that lifestyles are influenced by a myriad of factors which do not fall entirely under the ambit of
the health sector. Social, cultural, physical and economic factors(18) play a role in determining whether one will chose an action that is healthy
or not. The Singapore government’s approach is to change the context to make the individuals’ default decisions healthy, regardless of education, income or other societal factors.
Changing the context means that individuals expend less effort to benefit from these interventions as healthier options become more and more a natural part of everyday life.

Acknowledging the multi-dimensionality of health issues and that the whole is greater than the sum of its parts, a whole-of-government approach is used to influence behaviour change across the
key settings of the school, workplace and community.

Cultivating Healthy Habits from Young

From the start, health promotion has had a strong foundation in schools. Health services in schools were introduced as early as the 1920s to ensure the proper development of children. An
effective school health programme is considered as one of the most cost-effective investments for a country to improve both education and health(19) .
Establishing good eating habits from young can also help children maintain healthy weight and normal growth. They are also more likely to maintain a healthy lifestyle when they become
adults(20). This makes the school an ideal platform to reach and positively influence the health of school-going children, youth and their families.

Strong partnerships are essential to effectively influence behaviour change in students. In the preschool setting, the Early Childhood Development Agency (ECDA)(21) , the public agency looking into early childhood education, is a key partner. Beyond preschools, the key partners are the Ministry of Education (MOE) for both
primary and secondary mainstream schools, and the respective Institutes of Higher Learning(22) for the various tertiary institutes. Working together
with these partners creates synergy in bringing health promotion programmes to the hundreds of thousands of school-going children and youth.

Decal in a school promoting healthy eating habits.

One key initiative to cultivate healthy habits is to ensure that children and youth are eating well-balanced and nutritious meals. The “Healthy Meals in Childcare Centres Programme”, the “Healthy
Meals in Schools Programme” for primary and secondary schools and the “Healthier Dining Programme @ ITE(23) ” focus on developing environments that foster
healthy eating, thereby allowing children and students in these institutions to have convenient access to healthier food and beverage options. Cooks and canteen vendors from some of the
participating institutions have begun receiving hands-on culinary training from nutritionists and chefs in the preparation of healthier and tasty food.

Examples of healthy bento set meals served in childcare centres/ schools.

Food stalls in educational institutions are encouraged to offer healthier options by increasing vegetables and fruits in menus, and reducing gravy and fried food. Suppliers are also linked up
with canteen vendors to offer wholegrain rice, noodles, bread, and healthier oils. In terms of healthier beverages, currently only drinks with the Healthier Choice Symbol(24) are allowed in schools. The partnership with the Ministry of Education also looks at further reducing sugar content of drinks in vending machines and drink
stalls and the aim is for all schools to be on board this effort by January 2016.

The Healthier Choice Symbol logo.

For children and youth at risk of poor health outcomes, whether due to social or economic factors, a close partnership with the key stakeholders influential in their lives is a critical success
factor for effective intervention. This is the purpose of the Student Health Advisors programme which offers deeper engagement with such at-risk students, with the support of the schools.

These School Health Advisors have consistent follow-up and interaction with the students. This is done through individual or group-based support that is either requested by the students
themselves or through referrals by relevant school staff or the Health Promotion Board’s School Health Service. The support rendered includes mentoring on health issues such as smoking, weight
management and mental wellbeing. If necessary, at-risk students are identified to be referred to expert healthcare professionals and to adolescent health services. The presence of the School
Health Advisors in the schools strengthens existing health programmes and processes, as they provide evaluation of health promotion activities and health education, and identify opportunities in
schools for additional health promotion programmes.

Building a Healthy Workforce

The workplace offers an ideal setting and infrastructure to support the promotion of health of a large audience(25) . 67% of Singapore’s residents aged 15 and
over are in the workforce(26). At the same time, health trends among the working population are worrying. Obesity prevalence almost doubled among working
males, aged 18 to 40 years, from 7.2% in 2004 to 12.1% in 2010(27) . Also, because of Singapore’s ageing population, Singaporeans would have to stay in the
workforce longer. Employees who benefit from workplace-based health promotion will stay well longer, ensuring their employability post-retirement.

To ensure that Singapore’s workforce remain healthy, as part of the Healthy Living Master Plan, the Tripartite Oversight Committee on Workplace Health was set up in 2013. It oversees and drives
the development and execution of a workplace health roadmap, with strong tripartite partnerships that include public sector agencies, employers and employees. With the strong support, the
workplace has become one key setting for HPB to extend its outreach to more workers and develop structures and policies to create work environments which support healthy behaviour.

A key development under the Tripartite Committee is the integrated approach of “Total Workplace Safety and Health” to managing safety, health and wellbeing in the workplace. Traditionally,
organisations tend to focus on issues of workplace safety and workplace health separately. However, it is important to recognise that issues of employee health, safety and wellbeing are
interconnected and hence, an integrated approach is needed to better protect and promote workers’ health and safety.

Under the Total Workplace Safety and Health approach, workers and managers collaborate in a continual improvement process to protect and promote the health, safety and wellbeing of all workers.
With this focus, programmes on safety are integrated with those on health, creating synergistic benefits of improved productivity, reduction in absenteeism, employee retention and improved
quality of life(28) .

Info-graphic on “Total Workplace Safety and Health” in action.

Integrating Health-Promoting Facilities in the Community

Beyond reaching out to adults who are in the workforce, there is also a need to engage seniors and those who are not part of the workforce. This is the focus of the HPB’s community outreach
efforts and creation of health promoting facilities and programmes within the vicinity where one lives. This helps to influence everyday lifestyles and serves as the continuum of nurturing
healthy habits which extend from the school setting to the family unit.

Taking a leaf out of New York City’s book, the Healthy Living Master Plan brought together all who have a role in the design and construction of the built environment, including planners, urban
designers, architects, landscape architects, engineers and government agencies, to create an environment that enables all city residents to incorporate healthy activity into their daily
lives(29) .

Likewise in Singapore, leveraging connections across public agencies and existing infrastructure that have been built in the community, initiatives under the Healthy Living Master Plan focus on
integrating and enhancing such infrastructure to create easy access to health-promoting facilities and amenities. This brings healthy living options to the doorsteps of Singaporeans, making them
pervasive and easier for people to opt for.

One example of an interagency collaboration is between the Health Promotion Board and the Land Transport Authority on the Walk2Ride initiative. Active commuting is encouraged via improving the
walkability and user experience along sheltered linkways between transport nodes (e.g. Mass Rapid Transit train stations and bus stops) and typical destinations (e.g. schools) within a 400-metres
radius. This includes having rest areas that are retrofitted with health information and point-of-decision visual cues with health promoting messages. In collaboration with Town
Councils(30) , visual cues are also implemented at lifts and stairways of the housing estates to encourage residents to take the stairs instead of the lift.
This has been successfully implemented in three towns – Sembawang, Choa Chu Kang and Tampines - since last year.

“…we wanted more residents to choose to use these facilities. It was clear that we needed to fully connect the existing health promoting elements and create a conducive environment so that
residents could conveniently access these health promoting facilities and amenities.”

Visual cues in Tampines town encouraging residents to take the stairs instead of the lift.

Illustration of a Healthy Community Ecosystem providing convenient access to health promoting options.

Beyond physical infrastructure, having convenient access to healthy living programmes also encourages Singaporeans to live more healthily. Leveraging Singapore’s already strong physical
infrastructure and good network of parks, programmes have been developed to encourage utilisation of these spaces for physical activity.

One such programme is the Sundays @ the Park programme which was introduced in parks located within residential estates. The programme has been well received by residents and is an example of
public sector collaboration between the Health Promotion Board, Sport Singapore(31) and the National Parks Board(32) to provide residents with activities that benefit both physical health and mental well-being. Through this partnership, residents can enjoy a variety of
fun-filled physical activity programmes with family, friends and neighbours, including group exercise workouts (e.g. Zumba) and fitness boot camps.

By introducing these regular programmes, more interest is created among residents to enjoy the parks while participating in sports and adopting healthy lifestyles. This enables the partner
agencies to achieve complementary goals with the shared outcome of a healthier and happier community.

Residents signing up for Sundays @ the Park Programme.

CO-CREATION WITH THE COMMUNITY TO MOTIVATE HEALTHY LIVING

"It is only when individuals are able to exercise self-determination and contribute meaningfully to the communities they live in, that they feel they are fully human, and fully citizens of
this country."

At the public dialogue session for the Healthy Living Master Plan, the social approach to healthy living came up strongly in the discussions. A number of participants felt that social support and
influence were key to changing behaviour. This social element was seen as a strong motivating force to get people to live healthily.

This is consistent with the thinking that co-creation of solutions with the people in a community where people on the ground are brought together to solve specific problems, and engenders a sense
of ownership of the outcomes. Change is then further deepened and sustained when individuals move beyond their vested interests to care about the larger cause of the community(34) .

Therefore, on top of integrating the physical infrastructure and creating convenient access to healthy living options in the residential neighbourhood, co-creating solutions with the community is
important in influencing the adoption of healthy lifestyles and complements the whole-of-government effort. In this approach, community leaders are empowered to co-create with the health
authorities a vision of health for their community and advocate healthy behaviours.

Leveraging Peer Support to Encourage Healthy Habits

Community leadership, as well as leveraging networks and building relationships on the ground, are critical to the success of the initiatives in the community. One enabler for forging
relationships in the community for healthy living is through the Health Ambassador Network. Formed in 2011, the Health Ambassador Network recruits individuals who are passionate about
leading a healthy lifestyle to become advocates to inspire fellow residents in their towns to live healthily. Health Ambassadors are equipped with knowledge and skills on health topics, effective
communication and mentoring to enable them to reach out through their social networks to inspire others to lead a healthy lifestyle.

The more experienced Health Ambassadors are also provided with further training and development to empower them to drive health promotion initiatives. This includes forming and leading
interest groups, and mentoring new Health Ambassador recruits within the community. For example, the Fitness Kaki(35) interest group was formed in 2013
by Health Ambassadors who completed the Lose to Win(36) programme to encourage their friends to continue exercising regularly together, thus sustaining
the behaviour change.

Another example of getting the community involved is in the promotion of smoking cessation through the I Quit Campaign(37) which has been running since
2011. The I Quit campaign adopts a community-based approach to build a social support network to help smokers kick their smoking habits. The movement has reached more than 10,000 smokers through
the workplaces, hospitals and community since its launch. The smoker is supported in his journey to quit smoking by his family and friends, and the programme has also carved out a role for
successful quitters to help fellow smokers stub out for good. These quitters are given the opportunity to become I Quit Ambassadors for which they are trained and equipped with basic counselling
skills.

Creating Social Norms for Healthy Living

The use of peer support to motivate healthy behaviour change is not limited to the community setting. In the workplace, a sustainable model to encourage more people to adopt healthy behaviour is
via persuasive measures, such as social norming.

For instance, applying the diffusion of innovations concept(38) , HPB’s iRun initiative taps on early adopters at the workplace to start running interest
groups. Through social networks, a ripple effect is created where fellow colleagues and friends are influenced to join or start their own running groups. Over time, as more and more people join
the interest groups and adopt healthy lifestyles, the movement gains momentum and becomes self-sustaining when it diffuses through their social circles. The end result of this diffusion is that
people, as part of a social network, adopt the same healthy habits as their friends.

Working adults participating in the HPB’s iRun initiative.

PUBLIC-PRIVATE PARTNERSHIPS TO INFLUENCE BEHAVIOUR CHANGE

“Private sector can clearly play a crucial role in the fight against NCDs, particularly in terms of the products some companies produce that are among the risk factors that cause NCDs.”

World Health Organisation(39)

The battle against non-communicable diseases requires a concerted multi-sectoral effort. Involving the private sector is a matter of necessity, given that it is a big player in health – as
employers, producers of food, medicines and sports gear, developers of enabling technologies, and as consumers. As such, steps are being taken to engage private sector players to increase the
availability of healthy choices through strategic partnerships.

Partnering the private sector to provide healthier eating options

With more Singaporeans dining out these days and enjoying a vast variety of food choices, it is easy for people to exceed the recommended daily energy intake. According to the National Nutrition
Survey (NNS) 2010(40) , about 60% of Singapore residents exceeded the daily recommendation for energy, an increase from 48% in 2004. As such, tackling the
nutritional quality of food as well as the amount that Singaporeans consume is critical in battling obesity. This means working with private sector partners in the food and beverage industry to
address these issues.

Graph illustrating the National Nutrition Survey (NNS) data showing dietary excesses of energy and selected nutrients among the adult population between 2004 and 2010(41) .

Firstly, healthier meals are made more pervasive through the Healthier Dining Programme (HDP)(42) launched in June 2014. Partnering food service
providers, the Health Promotion Board is focusing on changing the equilibrium, to “tilt the market” for healthier options by creating supply and generating demand for healthier choices in the
whole value chain. Under the Healthier Dining Programme, marketing and incentive programmes like the Healthy-Go-Lucky Campaign(43) encourage
Singaporeans to select healthier options, including 500-calorie meals, resulting in reduced calorie intake from the consumption of healthier meals. These changes in dietary habits can then
generate new norms on the ground for healthier eating and create demand, enticing more new food business players to come on-board to supply healthier meals.

Example of The Healthy-Go-Lucky Campaign loyalty card given to consumers when they dine in at a food partner under the Healthier Dining programme, offering lower calorie meals.

With the implementation of the Healthier Dining Programme, 30 food service providers are now offering low calorie meals across some 1,000 food outlets and stalls in Singapore(44) . Most of these outlets and stalls use healthier ingredients, such as healthier cooking oils and/or whole grains.

Food stall decal indicating the use of healthier oil.

To curb the rising sugar consumption trend among Singaporeans, the “Life’s Sweeter with Less Sugar” campaign was introduced in October 2014 to encourage Singaporeans to choose drinks with less
sugar or no sugar. Similar to the Healthier Dining Programme, this campaign works on two fronts. Firstly, on the demand front, the public is nudged through gamification to opt for beverages
with less or no sugar, and water. Secondly, on the supply front, a supportive environment for healthy behaviour is created by partnering more than 1,000 drink stalls across Singapore.

Drink stall offering healthier beverages with less or no sugar.

Scratch and Win card when one participates in the “Life's Sweeter with Less Sugar” campaign.

CONCLUSION

o combat the health issues in a modern and ageing Singapore and aid in the battle against non-communicable diseases, Singapore will maintain its focus on ensuring that Singaporeans adopt and
sustain healthy lifestyles. As a “living” document, the Healthy Living Master Plan will continue to evolve as new challenges emerge and other innovative approaches develop over time.

Many of the ideas conceived under the Master Plan are innovative and experimental, often with no precedent. However, the underlying premise and objective remain clear - to systemically improve
the health outcomes of Singaporeans by bringing together different stakeholders to make healthy living accessible, natural, and effortless.

As Singapore continues to experiment, prototype and document health promoting initiatives in its own local context, it aims to build up a repository of knowledge that would be useful for anyone
interested in the practice of health promotion and the transformation of health outcomes.

(20)Health Xchange. Cultivating good eating habits – how to get your kids to eat well.
http://www.healthxchange.com.sg/healthyliving/DietandNutrition/Pages/Cultivating-Good-Eating-Habits%E2%80%93How-to-Get-Your-Kids-to-Eat-Well.aspx (Accessed 6 April 2015).

(21)The Early Childhood Development Agency (ECDA) serves as the regulatory and developmental authority for the early childhood sector in Singapore, overseeing all
aspects of children’s development below the age of 6, across both kindergartens and childcare centres.

(22)An Institute of Higher Learning in Singapore is a term for tertiary institutions which includes the Institutes of Technical Education, polytechnics and
universities.

(23)An Institute of Technical Education is a post-secondary government institution in Singapore that provides pre-employment training to secondary school leavers
and continuing education and training to working adults.

(24)The Healthier Choice Symbol (HCS) on packaged food products indicates that they are healthier options, and this helps consumers to make informed choices when
grocery shopping.

(29)New York City Department of Design and Construction. Active Design Guidelines: Promoting Physical Activity and Health in Design. 2010.

(30)Town Councils were set up following the passage of the Town Councils Act in 1988. It manages the public housing estates and related facilities within its
boundaries.

(31)A statutory board of the Ministry of Culture, Community and Youth, Sport Singapore’s core purpose is to inspire the Singapore spirit and transform Singapore
through sport.

(32)The National Parks Board is a statutory board of the Singapore government. It is responsible for providing and enhancing the greenery of Singapore – a City in a
Garden. NParks manages over 300 parks and 4 nature reserves.

(33)Laurence Lien, "Singapore's social safety net and the role of the non-profit sector", Speech at Singapore Economic Policy Conference, October 2008.

(34)Lena Leong. Engaging the Community to Achieve Better Health for all Singaporeans. November 2012.
https://www.cscollege.gov.sg/Knowledge/Pages/Engaging-the-Community-to-Achieve-Better-Health-for-all-Singaporeans.aspx#notes (Accessed 6 April 2015).

(35)Kaki: A Malay word which refers to a buddy or someone, one does things with.

(36)Lose To Win is a weight management programme by HPB. It is a fun and interactive way to get fit under the guidance of certified trainers and with
like-minded individuals, through exercise, nutrition and goal-setting.

(37)I Quit is a is a national anti-smoking social movement introduced by HPB in 2011, which adopts a community-based but personalised approach to build a network of
support that helps smokers make their first or next attempt to quit smoking

(38)Boston University School of Public Health; Diffusion of Innovations Theory. http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-Models4.html.
(Accessed 15 November 2014).

(39)World Health Organisation. What is the role of the private sector in the high-level meeting on NCDs? http://www.who.int/nmh/events/un_ncd_summit2011/qa/qa6/en/
(Accessed 6 April 2015).

(40)National Nutrition Survey 2010.

(41)National Nutrition Survey 2010.

(42)The Healthier Dining Programme is an initiative to encourage food and beverage companies to provide healthier meals for their customers (e.g. lower calorie
meals and meals using healthier ingredients such as whole-grains and healthier cooking oil).

(43)The Healthy Go Lucky Campaign is a reward programme to incentivise people to eat healthily. Singaporeans can win cash prizes when they purchase healthier choice
meals at participating outlets.